Assessing whether NSAID use is appropriate

General information

NSAIDs are the preferred analgesics for acute dental pain because of their anti-inflammatory actions, efficacy for bone pain and ability to reduce opioid requirements, nausea and vomiting, and improve pain relief when used as a component of multimodal analgesia¹.

Before prescribing an NSAID, weigh these potential benefits against the potential harms in the individual; the risk of harm depends on patient factors (see below) and the NSAID used (see Choosing an analgesic regimen for patients at risk of NSAID-related toxicity). Consider accessing the patient’s electronic health record to obtain more information on their health status. If unsure of the safety of short-term NSAID use for a patient, consult a medical practitioner.

There is a low risk of harm when NSAIDs are used short-term by healthy people who are not taking other medicines. However, even in these patients steps should be taken to minimise harm; see here.

Conversely, NSAID use is contraindicated in some people and should be avoided in others because of a significant risk of harm—see Patients who should not be prescribed an NSAID by a dentist for patients who should not be prescribed an NSAID by a dentist. If paracetamol is not expected to provide sufficient analgesia in these patients, consider alternative pain management strategies or refer the patient to a medical practitioner.

Deciding whether it is safe to prescribe NSAIDs in patients with risk factors for NSAID-induced renal, cardiovascular or gastrointestinal toxicity is more complex. Consider the cumulative risk of NSAID toxicity if more than one risk factor is present.

The use of NSAIDs in elderly patients and pregnant or breastfeeding women requires extra consideration.

Renal toxicity

Acute kidney injury is a serious adverse effect associated with all NSAIDs. Risk factors for NSAID-induced acute kidney injury include:

• older age
• pre-existing kidney impairment
• volume depletion (eg dehydration, sepsis) or effective arterial volume depletion (eg due to heart failure, cirrhosis, nephrotic syndrome)
• current use of angiotensin converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), diuretics or other nephrotoxic drugs.

The risk of acute kidney injury is cumulative—for example, the risk is significantly increased if an NSAID is co-administered with an ACEI plus a diuretic, or if an older patient taking an NSAID develops an acute illness associated with dehydration.

To choose an appropriate analgesic regimen for patients at increased risk of renal toxicity, see here.

Cardiovascular toxicity

Although all NSAIDs can cause cardiovascular toxicity, not all are equally likely to do so—evidence is evolving. Furthermore, the relationship between duration of NSAID use and onset of toxicity is not fully understood. It is clear that the risk of cardiovascular toxicity increases with longer durations of therapy and higher doses. Short-term use (ie less than 5 days) of NSAIDs does not significantly increase the risk of cardiovascular events, and can reduce the requirement for opioids.

Risk factors for increased cardiovascular toxicity with NSAID use include:

• established cardiovascular disease (eg myocardial infarction, stroke)
• risk factors for cardiovascular disease (including smoking, older age, elevated blood pressure, dyslipidaemia and diabetes).

If a decision is taken to use an NSAID in a patient at increased risk of cardiovascular toxicity, see here for suitable choices.

Gastrointestinal toxicity

Risk factors for increased gastrointestinal toxicity with NSAID use include:

• older age
• history of upper gastrointestinal bleeding or peptic ulcer disease
• Helicobacter pylori infection
• current use of drugs that increase the risk of upper gastrointestinal bleeding or perforation (eg anticoagulants, antiplatelet drugs, selective serotonin reuptake inhibitors [SSRIs], serotonin and noradrenaline reuptake inhibitors [SNRIs], systemic corticosteroids)
• significant comorbidity
• smoking.

If a decision is taken to use an NSAID in a patient at increased risk of gastrointestinal toxicity, see here for suitable choices.

Elderly people

Assess the need for NSAIDs in elderly people particularly carefully. Elderly people are generally at increased risk of renal, cardiovascular and gastrointestinal adverse effects of NSAIDs. Elderly people are also more likely to have comorbidities and take other drugs that increase their risk of NSAID-related adverse effects.

If a decision is taken to use an NSAID in an elderly patient, see here for suitable choices; NSAIDs with a short half-life are preferred (see NSAIDs commonly used in dentistry).

Women who are pregnant or breastfeeding

If possible, avoid NSAIDs during pregnancy. Evidence on the safety of NSAID use during the first 8 weeks of pregnancy is conflicting. NSAIDs should not be used beyond 30 weeks of gestation because they can be associated with adverse maternal and fetal outcomes. NSAIDs are best avoided beyond 20 weeks' gestation because of the risk of oligohydramnios (a deficiency of amniotic fluid). If use for longer than 48 hours cannot be avoided between 20 and 30 weeks' gestation, seek medical or obstetric advice—if a decision is taken to use an NSAID, a nonselective NSAID should be used at the minimum effective dose for the shortest time possible and ultrasound monitoring of amniotic fluid may be considered.

COX-2–selective NSAIDs should be avoided during pregnancy because, compared to nonselective NSAIDs, there are fewer data on their use.

For further discussion on the use of NSAIDs in the perinatal period, see Potential harms of NSAID use during pregnancy.

Small amounts of NSAIDs are excreted into breast milk; however, these amounts are unlikely to cause harm to breastfed infants. Ibuprofen is the preferred NSAID for women who are breastfeeding. Advise breastfeeding mothers to feed their baby just before taking their medication, to minimise the amount of drug in the breastmilk.

Before prescribing an NSAID for a woman who is pregnant or breastfeeding, consider the general principles of drug use in pregnancy or breastfeeding, as well as the safety of the individual drug.